ADHD and Therapy Don’t Always Get Along. Let’s Talk About It.
Support for ADHD is incredibly lacking. Medication often seems to be the only thing available despite psychosocial treatments being recommended alongside medication for ADHD. So what actually are these psychosocial treatments and are they any good?
Often when people go for ADHD diagnosis they’re left a little bit lost at the end. Most of the time they’re given the diagnosis and let go. If they’re lucky, they’re given a prescription for medication as well, but that’s about it. The rest are left to figure out on their own.
Much of the ADHD research doesn’t just recommend medication, though it recommends a combined approach of medication and psychosocial interventions. Often I see that sentence written just like that without really any elaboration on what psychosocial interventions actually are. So I’ve done some research into the psychosocial interventions what they are how effective they are. And that’s what I’m going to talk about today.
You might have guessed from the title of this video that one of those things is mental health, specifically talking about CBT therapy, in this case. So spoiler alert we’re going to talk about that. But before we do, let’s talk about what psychosocial interventions are in general.
I found a study (Lauder et al., 2022) focused on reviewing interventions used to support ADHD adults at work and in this case it looked at 143 different studies about different interventions, medication and psychosocial, and concluded that none of them have really been that well evaluated when it comes the work place.
Of those psychosocial interventions, it sorted them into a few different categories. Those are: CBT skills training, attention training, coaching, mindfulness and the vague catchall of alternative therapies. So if we take this all at face value, all people who are diagnosed with ADHD should be pointed to one of these things as well as or instead of being put on medication.
One of the best executive function training methods was actually one I did throughout my youth without knowing: The martial art of Taekwondo.
This means that, based on recommendations, every single person who gets an ADHD diagnosis should be pointed to CBT, some kind of executive function training (that’s what I’m categorising skills training and attention training into), some coaching mindfulness or whatever the vague alternative therapies are. That’s not happening, is it?
But say it was happening, say that every single person who an ADHD diagnosis got recommended or sent one of the things. What would be the outcome if that happened? Turns out there’s not a whole lot of research in the space but from what we have, we can start paint a picture of what is actually useful and what is a bit of a waste of time.
Now I’ve spoken about executive function training in a couple of previous posts (there’s one linked to each word there). And so if you’d like to know a little bit more about that, I recommend you give them a read. I’ve also spoken a little bit about mindfulness and how it doesn’t really work for me particularly well, so I’m not going to talk about that today either.
What I am going to talk about is the two categories left: CBT and coaching. Note that I’m biased here. I am a leadership coach. I’m a leadership coach because I love coaching and see how effective it is. But I didn’t actually go out looking to make this post. I’m making this video because I stumbled across a lot of research that I think is really relevant to this conversation.
So I’m going to start by talking about CBT because I see recommended for ADHD a lot. It’s even recommended by the NHS for treating ADHD. When I speak to people and see anecdotal conversations online. I often see that it also can be just a really bad experience and I do wonder about the efficacy of the CBT that I personally experienced as well. So I went looking for research and stumbled across the paper: Experience of CBT in adults with ADHD: A Mixed Methods Study.
My brain process for this picture: Hm, I need a picture related to therapy. What do I think of when I think of therapy? Hey, they featured therapy heavily in The Sopranos! What is a good visual image for The Sopranos? DUCKS! Shame they’re not in a pool…
The study did exactly what it says on the tin and surveyed and had in-depth interviews with participants talking about their experience of CBT as someone who has ADHD. They call it a mixed method study, but actually it has kind of mixed results as well.
They actually found that the overall experience of the participants in the study was really negative. All but one of the participants had pretty scathing things to say, reporting things like the CBT they received was “essentially incompatible with their experiences of ADHD”. They spoke about their working memory deficits not being taken into account, executive function and emotional dysregulation struggles being ignored and one participant even said it made them feel worse for going there. That’s not good enough.
Now before you accuse me of being anti-therapy. I’ve given you the results without giving you the full nuance here. These participants took part in generic CBT given out in the UK but one participant did have a better experience and that’s because they did ADHD specific CBT. I want to read you the quote from that participant because it’s gonna be relevant to later here we go:
“What I liked about it was that I understood how my mind worked. So it was really kind of understanding what the strengths I think of ADHD were. I just felt that I’m more accepting of myself and I’m more aware of myself and I’m more aware of my kind of behaviours if that makes sense”
How do you feel about the fact when we stock image search the word “mind” a Rubik’s Cube comes up? I would bet money on there being an Autism association in there somewhere..
I think this is the crux of it. The research, the experts, all the positive recommendations for CBT for ADHD likely come from CBT being done in an ADHD friendly way. In a way that is specific to people with ADHD. But not all CBT follows this.
So I’m not anti-CBT. I’m not anti-therapy. So many of my clients have had both coaching and therapy. At the same time I’m actually really pro therapy, but it needs to be done in the right way in a way that is ADHD friendly otherwise it might just be a waste of your time.
So now we move on to coaching and I’m actually pulling from two separate studies here. The first is The Experience of Coaching for Women with a Late Diagnosis of Attention Deficit Hyperactivity Disorder and the second is Why do adults with ADHD Choose Strengths-Based Coaching Over Public Mental Health Care. A Qualitative Case Study from the Netherlands.
There are three themes I want to pull out from these two studies. First is executive function training, which I’ve already mentioned I’ve covered elsewhere on this blog. The second is identity and self-confidence, and the third is the strengths-based thing. We’ll come back to that one last.
The reason for this is because those latter two themes are things I actually do. Executive function training is important, but it’s not where I spend my time and actually if clients are coming to me just executive function training, I recommend them to go elsewhere because it’s not what I do best. But self-confidence and learning about your strengths. That’s right in my wheelhouse.
So let’s talk about identity and self-confidence first. This was super important in the study of women with ADHD, both in terms of their identity with regards ADHD, but also with regard to their gender as well because many of us women do get missed as children because so much of ADHD research has been focused almost entirely on men until recently.
Stock image searching the word “girl” showed lots sitting quietly which kind of proves the point a little. But this one? She seems full of beans!
So not only was this about processing their new identity as a woman with ADHD , but it was also about processing that with regards to things like their role in the home with caring that they might be doing for a parent or child, with trying to juggle the domestic responsibilities as well as work responsibilities at the same time.
Part of why I find coaching so valuable is because it’s personalised, it’s not restricted to a particular set of steps that you should follow. Coaching done well looks at the whole person. So yes, I’m a leadership coach but if one of my clients comes in saying that they have something going on with their kid at school that they need to work through, and that’s more important to them today then we can talk about what’s going on with the kid at school.
This flexibility is important because often my clients change how they conceptualise themselves and their identity over time and we are changing how we approach things in response as it develops. Sometimes the journeys my clients go on surprise me. But the beauty is that as we go on the journey together, we get to explore that process in real time as they discover it.
Part of this identity complexity is how much self blame and self-doubt people have internalised. They often feel they’ve been judged all their lives or feel like a failure and the study highlights this that this was so bad, to the extent that they were even concerned they would fail at coaching. As an aside, the only way you can fail at coaching is if you don’t participate. As long as you show up, engage in good faith and spend some time reflecting, you can’t fail. Trying to emulate a different neurotype all the time is hard and a lot of this self doubt and self blame was a reaction to that.
So I was trying to think of something to illustrate “strengths based” and my current hyperfixation is calisthenics, so here’s someone doing a skill I hope to one day be able to learn…
All participants in the study, however, found that ADHD coaching positively enhanced their lives both with respect executive function, training and identity. The study suggests the coaching helped them exercise self compassion and move towards autonomy and growth.
The study also notes something important. All participants had achieved an undergraduate degree, one of them even gaining a postgraduate degree, and they stated that education level for a number of reasons. One of which is the fact that there is a stigma when it comes to people with ADHD and being perceived as less capable, one that frustrates me to this day.
In addition to this, parents and teachers expectations of students with ADHD tend to be lower than for their non-ADHD peers and there also tends to be a correlation between girls of high IQ and high verbal IQ being misdiagnosed or just completely not diagnosed at all until much older.
This stigma is particularly relevant to the second paper which looks at why adults with ADHD choose strengths-based coaching over public mental health care in the Netherlands. Because one of the things participants loved in this paper was the strengths-based approach to coaching that they found.
According to the study, “Strength-based coaching aims to reinforce and utilise innate competencies to achieve goals established by both the client and the coach”. And this paper is particularly interesting because the strengths-based coaching isn’t free, like the mental health care they’re comparing this against. So why are people paying for coaching instead?
To investigate, this study held 23 semi-structured interviews with clients of a private coaching centre in the Netherlands explicitly looking for people who were critical in a positive or negative way towards the coaching centre to try and get a less biased opinion. They asked questions about the experience of the current, previous treatments and favourable and unfavourable characteristic of therapies, therapists and coaching in general.
Perhaps unsurprisingly, given the earlier conversation, many of them had negative experiences with therapy which is very unfortunate. When it came to coaching. However, they were much more complimentary.
One of the big differences is that the coaching was personalised and unique to them. They mention that they’re not a number and they’re not just trying to follow a thing of what they should be. The treatment was personalised and instead of it being a case of “everyone else has these meds and is fine”. Or “These meds treat ADHD so take these meds”.
They appreciated working together, with both coach and client developing a personal relationship. They use the term safe, something I strive for my clients to feel. As most of the coaches had ADHD too, they felt understood and accepted.
Sometimes when I have ADHD moments in my own business, I’m really glad that this is relatable for my clients and not people shaking their head at me like maybe a neurotypical person would do. Like the time I told my client I had sent her attachment and completely forgot to attach it. So I thought okay, let’s follow up with an attachment separately and make a joke about it and as expected she found it funny and it didn’t make me look like I was completely incompetent and unprofessional.
Sometimes I feel like I just need Clippy back to say “Have you remembered to add an attachment?” Given my target audience for coaching, I hope most of you get this reference.
They mentioned that while mental health care had painted that ADHD is chronic, something they would never overcome, coaching was more forward-looking, solution focused, giving them space to grow.
However, not everything about coaching was positive. Some participants felt invalidated when the coach was too strengths focused and wouldn’t acknowledge the things that they were struggling with. They found this insincere and that it was a coach avoiding taking responsibility to fully support them.
I don’t like this. I have probably made that mistake before my early days of coaching and then stayed up all night kicking myself afterwards. I’d like to think my clients always feel validated by me now, but I do appreciate that I’m not a perfect human being and I do make mistakes and it’s important to me to grow and become a better human being as my clients grow too.
Another problem was coaches telling too many personal stories to try and be relatable. This one actually surprised me because that goes against the ethos of: coaching is not about me, but my clients. I’m actually reluctant to share a story about myself, unless the client explicitly asks. I’m happy to be relatable. But that time is about them, not me.
This paper was pretty scathing on therapy and pretty bullish on coaching. But what is important to note, and the paper does acknowledge this, is that just because therapy didn’t work for the sample size of 23 people doesn’t mean it doesn’t work for others. There will be people out there who have amazing experiences with therapy and amazing experiences with coaching to but everyone is different and so different things work for different people.
And I will note here that the coaching I do is slightly different to the coaching in these studies, there’s a lot of overlap, but my focus is the workplace. I still coach the whole person, so sometimes we do talk about things outside of work, but for the most part I’m helping people advance their careers.
But in order to do that. I employ these positive strategies that have been spoken about. We talk about self-confidence. We talk about identity. Many of my clients do strength assessments. We talk about the things my clients need to get them to where they want to be and sometimes that does include a bit of executive function training.
So to bring this post to a close, I want to give you the conclusion of the final study I’ve been talking about which says “clients felt that coaching had a positive and substantial impact on the lives and well-being” and it’s a pleasure to do this for my clients as well.
References:
Experience of CBT in adults with ADHD: A Mixed Methods Study (William et al., 2024)
If this resonates with you and feel you would be interested in talking to an adhd and autism-friendly coach, feel free to get in touch. If you’re looking for more blog posts, you can find them here.
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